Transcription of Return Completed Form To - Prometric
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Return Completed Form To - Prometric
Telephone (208) 334-6620 Toll Free (800) 748-2480 Fax: (208) 334-6629 Return Completed & Signed Form To: IDAHO nurse AIDE REGISTRY DIVISION OF LICENSING & CERTIFICATION BUREAU OF facility STANDARDS IDAHO DEPARTMENT OF HEALTH & WELFARE 3232 ELDER STREET BOX 83720 BOISE, ID 83720-0009 nurse AIDE CERTIFICATION RENEWAL FORM (PLEASE PRINT CLEARLY) NAME: _____ SOCIAL SECURITY #: _____ ADDRESS: _____ DATE OF BIRTH: _____ CITY: _____ EXPIRATION DATE: _____ STATE/ZIP: _____ PHONE NUMBER: _____ (Your renewal will not be processed more than 45 days prior to your expiration date) You must work at least 8 hours in a PAID CNA, nursing/nursing related position in the two years before your expiration date to be eligible to renew for another 2 years. You must sign below to authorize your employer to release employment information to the Idaho nurse Aide Registry.
idaho nurse aide registry . division of licensing & certification – bureau of facility standards . idaho department of health & welfare . 3232 elder street . p.o. box 83720 . boise, id 83720-0009 . nurse aide certification renewal form (please print clearly) name: _____ social security #: _____
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